Nothing veterinary related

My best friend from vet school and her (new) fiance are visiting for the weekend. We spent Saturday and Sunday at my uncle's cabin in Morganton, NC. It was a stunning weekend in western NC. We spent some of the first day touring the area in the Mule, as I showed my friends around my uncle's property. Dinner was prepared by the fiance, and he is a gifted chef (he used to work as one professionally). I have rarely had food such as he made (filet mignon with brandy mushroom sauce, asparagus, and purple potatoes). We rounded out the night by watching the stars for a few hours (no light pollution in the middle of nowhere) and then with Top Gun on the projector screen.

The temperature today was in the mid-70s, and the humidity was very low. It was absolutely gorgeous. We hiked up Table Rock today (visible from my uncle's land) and got a breathtaking view of the Linville Gorge and the Amphitheater (much of where The Last of the Mohicans was filmed). It was a great 2 mile hike, and Heidi did wonderfully. We also drove onto the Blue Ridge Parkway and hiked along the road a bit to savor the panoramic view of the Smoky Mountains. How I miss home! How I miss the mountains! I once read about a famous photographer that said that the Smoky Mountains are the hardest to photograph. After attempting to do so myself several times, I agree. Nothing captures that absolute silence and vastness of some of the views along the Blue Ridge Parkway. They are dizzyingly gorgeous. If you've never visited, it is a definite must-see.

We're home again and tired...they leave tomorrow, and it's back to work for me. I'm worn out! My parents have been here, my best friend, I'm bottle raising 3 kittens, one of which is doing poorly and needs subcutaneous fluids and occasional dextrose...I don't feel like I've caught up on my sleep at all. Alas, I probably should do so before Wednesday!

(P.S. - That picture of the grey rectangle with greenery in the center is through an aqueduct hole in the Blue Ridge Parkway. You can see straight down for about 50 feet. My whole foot could fit in that hole. Made me kinda nauseous but made for a great picture!)

(Oh and P.S.S. - Doesn't Heidi look wonderful? She's been running with my husband, and we try to take her wherever we go that she can be outside running. She's building up muscle and has gained weight, up from 55# to 68#!)

Miscommunication

We had a terrible mis-communication with an owner recently. She brought in her 3 year old mixed breed dog, Marti. Marti was exhibiting severe neurological signs - a head turn to the left, cervical neck pain, occasional seizure activity (per the owner, we never saw the seizures), and mild mental stupor.

Our differentials were meningitis/encephalitis of some sort - possibly GME or NME, or something like West Nile virus.

The referring veterinarian tried as hard as she could to get the owner to take Marti to a neurologist for diagnostics and treatment. The owner declined. As a result, we wound up admitting the dog one night last week to our hospital.

The treatment for NME is steroids, which we started Marti on. Her condition deteriorated over the next couple of days, but the owner still refused to take Marti to a neurologist. I took over the case on the dog's second night in the hospital.

When Marti transferred back, she was lethargic, poorly responsive, and weak. She could not lift her head. I again begged the owner to seek a neurologist's opinion. It was at about that time that my technician paged me to the ICU. I was confronted with this:





That, my dear readers, is what REAL bloody vomit looks like.

Back I went to the room. I looked at Marti's owner, a young, intelligent, well-spoken women and asked, "had you been giving anything at home prior to when we first saw Marti?" She nodded. "Baby aspirin," was her reply.

My stomach turned. "But I told the other veterinarian," she said. "At least, I thought I did. Maybe I only told her that we gave aspirin LAST time this happened." (The first episode had been about a month previously).

What happened to Marti is that she received aspirin, a non-steroidal anti-inflammatory medication (NSAID), as well as a steroid. These drugs work on the same inflammatory pathway, and using 2 at once can cause SEVERE, SEVERE damage to the GI tract. Why? NSAIDs AND steroids inhibit prostaglandins. These PGs are responsible for mediating inflammation and down-regulating them will help dampen the inflammatory response. PGs have good effects, too. They mediate blood flow to the kidneys and function in acid secretion in the stomach. When you suppress them with NSAIDs and steroids, you lose the good AND the bad. This is usually not a problem unless you 1) take massive dose of NSAIDs or 2) you MIX steroids and NSAIDs. Even though we were using a tiny dose of steroids, it was enough to cause a horrible, bleeding ulcer.

The owner finally consisted to transfer Marti to a specialist (after seeing the vomit firsthand). By the time Marti arrived at the local specialty clinic, her PCV (measure of red blood cell mass) had dropped from 46% to 32%, indicating internal bleeding. This was occurring into her stomach from her bleeding GI ulcer. After much discussion, Marti's owner elected to euthanize her.

It was a terrible, terrible thing and an important, potent reminder of why we - as veterinarians - should always, always, always ask, "Have you administered any medications to your pet lately - EITHER prescribed OR over the counter?" And that's why you, as pet owners, should always, always, always tell your veterinarian if you have given something to your pet.

My dad

In not crazy news

Great week ahead...

My parents coming today for a 3 day visit - SO EXCITED.

My best friend from vet school and her boyfriend coming on Friday for the weekend.

Oh, and 3 new bottle kittens. Ha. All 3 from different litters and arrived at different times over the last 2 weeks. I have a problem.

OMG ...the crazy.

Saturday night, we were sitting on our collective fannies...when the door burst open. A young woman staggered - and I mean staggered - into the ICU carrying a limp dog.

"Heyyyyyyy," she slurred, "I gotta unconscious dog."

We took the dog from her, and my tech herded her into the waiting room.

The dog was not unconscious. It was dead. She had BEEN dead for about 2-3 hours, as she was in full rigor mortis. I could feel the heat baking off of her body. Rectal temperature was too high to read (>108). She had bruising all over her gums, ears, and skin. She was fairly classic for a heat stroke (it had been in the high 90s all day).

The plot thickened when the actual owner showed up (girlfriend to Drunky McBrewster in the waiting room). She was sobbing uncontrollably, gasping and hiccuping for breath. When she saw her girlfriend - drunk or as stoned as a fiend - she uttered a guttural, "GET OUT." The girlfriend scuttled out the door.

Meanwhile, the owner turned to my tech and said the following, "She's messed up on drugs. She doesn't know what's going on. I came home from work and found the house trashed, blood everywhere, and Betsy (the dead dog) in the TRASH CAN."

It's not funny. It's not funny in any way, shape, or form, but I felt hysterical laughter bubbling up inside me. The drunk/stoned women threw the dog in the trash can! Seriously!?

I'm doing it

**Also - if you read my blog regularly, please become a follower. I know there are many lurkers out there, and I'd like to know who you are. I read your blogs too!

After yet another email from my retired English professor grandmother imploring me to follow my true calling (?? funny, I thought I was doing that), I have officially started working on my book. I've skimmed the market, found that veterinary medical books are very popular (Tell Me Where It Hurts, All Creatures Bright and Beautiful, etc) and have gleaned that there are no current books like the one I am writing. It's already coming together quite well after 5 hours of concerted effort and organizing.

Here is my question for you, my readers:

1) Would you rather read a book about veterinary medicine written as a cohesive, linear story - i.e. I got up, went to work, this happened, came home, this happened? Or would vignettes a la James Herriot with a grand, unifying theme be more interesting?

2) Would you read a book about veterinary medicine? I assume so, since you read my blog, but I'd like to know if you'd buy a book on the subject?

To clarify

For anonymous - the general layout is similar, although what is called the fallopian tube in women is called the uterine horn in dogs.

Just had a feeling

The dog in front of me was bouncing off the walls. Her vitals were absolutely normal. Her abdomen was not painful when I palpated it. She was at 63 days gestation (the normal gestation period for a dog). The owner had been taking her temperature at home, and it had dropped, as it should, on Wednesday. One way to predict labor in dogs is to measure body temperature. About 24 hours before labor begins, the body temperature will drop below 100 degrees. This dog's temperature had dropped on Wednesday. No labor ensued. The temperature had gone back up about a day later, and then, nothing. The dog felt great. She'd had no contractions, no sacs or fluid passing from the uterus. Everything looked normal. Except something just wasn't right. I couldn't put my finger on what.

I xrayed her and counted 5 puppies. I ultrasounded her and counted 5 puppies, all with normal heart rates of about 180-200. They were all moving, and everyone looked healthy and vigorous.

Yet, I still just had a feeling.

I talked to the owner. We discussed taking a wait-and-see approach, trying oxytocin (Pitocin) to induce labor, or a c-section. After much debate, the owner elected to go ahead with the c-section.

Imagine my surprise to find that the dog had suffered a partial uterine torsion. Just like humans, the uterus is shaped like a y. The body is at the base, and the y shape is the horns. The puppies are in the horns. In this dog, the left horn had twisted and was underneath the right horn. As I de-rotated the horn, puppies started falling out of the horn. It had ruptured, but due to its position, the other uterine horn was holding all the fluid and the puppies (all ALIVE!) in place.

It was the oddest thing I have seen thus far. I don't know what told me that something wasn't right, but I am so thankful that the owner decided to do a c-section! Otherwise, I would have sent that dog home, and she would eventually have become septic, the puppies likely would have died, and mom could have too. Sometimes, you have to listen to that little voice, after all.

Good deed ...

Every time I am reminded of how "no good deed goes unpunished", I swear never to do a good deed again. Yet, last week, I did exactly what I swore I would not - TWICE.

At around 2am Thursday night, a woman came in with her small breed pregnant dog. She'd had 1 puppy, and then just stopped. Over 6 hours ago. She was pushing intermittently, but her contractions were not that strong or prolonged. Nothing was happening.

The owner's finances were limited. We started with an abdominal xray and an ultrasound. I counted 4 puppies but could only find 2 heartbeats. More concerning than that (ultrasound isn't great for finding all hearts in multiparous bitches) was the fact that one fetus was directly in front of the birth canal, bent into a u-shape. I suspected that the puppy was dead and obstructing the uterus.

I recommended a c-section. The owner had extremely limited money. She confided in me that she'd been diagnosed with ovarian cancer 2 years ago and was now in remission. She'd undergone chemotherapy, costing $12,000/treatment (for a total of 10!), and her insurance wouldn't cover it. "As a result," she whispered to me, with tears running down her face, "I had to declare bankruptcy." She said this with deep shame, explaining that she'd always taken pride in her credit score and her responsibility with money.

She asked for no favors, saying that she would get her dog to the vet first thing in the morning for a cheaper c-section. I couldn't let the dog wait, otherwise surely, both other puppies would die.

So, I did a discount c-section. In the end, the bill was $600 (the actual bill was $1200). The puppy in front of the cervix was indeed very dead and obstructing the uterus. The other 2 puppies were alive and well. Mom was grateful, patient while waiting in the lobby for the surgery to be over, and voiced her gratitude by giving me a hug.

I have got to get that SUCKER on my forehead scrubbed off!

Real life in watercolor

Sweeping the crepe myrtle petals off the sidewalk today, I was suddenly almost paralyzed by the realization that this is my real life. I'm an adult. I own a house, 2 cars, 10 pets, a garden, some plants, and shortly will have real life insurance. I'm an adult with a real job in the real world. No longer an ephemeral student. Then I felt incredibly ancient (at 31) and frightened by my own fragility and mortality. Ah, life.

Exercise in frustration

Nothing - absolutely nothing - is as frustrating as the failure to communicate with an owner. That feeling of wanting to knock your head against the wall repeatedly until blood spills out of your ears is never a good one.

Last week, we were presented with a THIRTY POUND miniature dachshund. In case you aren't familiar with breed standards, a mini dach female should weigh in at about 11 pounds. This dog was morbidly obese. She had also developed diabetic ketoacidosis, a nightmare to treat under the most ideal circumstances and with all the finances in the world.

These were not ideal circumstances at all - a terribly obese dog with a mentally handicapped owner that had serious financial limitations.

The referring veterinarian that diagnosed the dog tried to talk them out of treatment and heavily recommended considering euthanasia. The owners refused, then changed vets the next day (after starting treatment at the original vet). The dog came to us on ER for overnight care. We discussed again that this disease is often fatal, usually recurs, and can cost upwards of $3000 to effectively treat.

The owners wanted to continue despite our heavy caution. Over the next 3 days, the situation deteriorated. Financially, the owners could not accept the burden. They maxed out their CareCredit, pawned their wedding rings to get more money, and they were considering selling their car on the last day that I saw the dog. She did not noticeably improve over her 4 days in the hospital, although her blood glucose became more manageable.

Over the course of 3 nights, I knocked about $200 off the bill. And the dog still did not get better. She was eventually discharged by the referring veterinarian and sent home on injectable insulin, although she was nowhere near ready. The finances were just too tight.

In the end, no one feels good in that situation. We WANTED to help the owners, but they were absolutely stubborn in their refusal to understand the big picture. This dog WILL be back in 2-12 months with a recurrence of DKA. They are already feeding her tuna in heavy oil at home - AGAIN (she also had pancreatitis). They are obsessively checking her blood glucose and adjusting her insulin based on the results (a big no-no!), crushing up human glucose tablets and administering them, and basically screwing up everything the vet is trying to accomplish in regulating her diabetes.

It's a shame when communication fails. No one wins in that situation.

AWOL

Sorry I've been a slacker about posting lately. My last week "off" was anything but. I never caught up on my sleep, and as a result, this week, I feel like a slug that has been heavily salted...

It started with driving to Atlanta after working all night the weekend before last. I spent 2 days there, came back. My brother came to visit and spent the night. I cooked a big meal for friends. I rode every night I was off (I jumped 3 foot fences, my first time!). I cooked and cleaned the house. I went to a doctor's meeting. We met with a financial planner (who told us we're doing a good job with our finances, yay!).

The piece de resistance was the drive to Nashville (approx 7.5 hours ONE WAY) to see Arcade Fire - arguably my favorite band in the world - live at the famed Ryman Auditorium. I bought the tickets a while ago in a fervor of excitement, not really thinking the drive through. When it hit home how exhausted I was, I reluctantly decided to sell them on craigslist. As it turned out, AF did not want the tickets scalped, so they were paperless and non-transferable. So rather than waste $180 worth of tickets (I bought 3), I made the drive. It was worth every second in the car. It was the BEST concert I have ever seen. I am not exaggerating, and I go to a lot of shows (see the video). You might have heard Arcade Fire's song Wake Up in the "Where the Wild Things Are" trailer.



In other news, all 4 of my last bottle kittens went to great homes - thankfully. Of course, they were gone approximately 72 hours when this showed up:



Now I am a slave to the bottle and the KMR again. **Sigh**







Some fat ponies that came to the fence as we rode by:

Hug the ones that you love dear today.

My first cousin, whom I grew up with as another sibling, lost his 3rd child yesterday about 4 hours after her birth. She was diagnosed in utero at about 6 months with anencephaly (no development of the forebrain/cerebrum). My cousin's wife elected to carry her to full-term and deliver her. They understood that these babies live - at the VERY most - a few days, more likely a few hours. Erin was born yesterday and lived for a few hours. My aunt and uncle were able to get pictures of her and at least get to meet her.

Keep her and my family in your thoughts and prayers. This has been especially hard on my grandparents, as we lost my 2 year old cousin to a tragic drowning a mere 4 years ago.

Sidenote

I want to be clear that while I am going through a trying time at work - I am still very happy with my job overall. I still love going to work and love the challenge it presents. There are many really great things about my job - REALLY great things. We - collectively - are going through a very rough patch and morale is low. It is a patch, though - and we will get through it.

Anxiety, you are not my friend.

It's been a long time since I had true, lasting anxiety. I have free-floating, rather nebulous anxiety sometimes, and other times, a very concrete anxiety related to some problem or other, but last night took me back to the panic attacks of my early 20s. I couldn't sleep at all. I was up until 6am this morning, despite being completely worn out and WANTING desperately to sleep. My anxiety is mostly focusing around work and all that is going on there, but that swirls around everything in my life because my job is such a big part of who I am. The anxiety starts to taint everything - I fretted about money, my marriage, my lack of kids at this stage, my house not being finished, as far as decor goes, savings - do we have enough, what else should we do...My mind raced all night, my chest hurt, and I couldn't rest.

Ugh. I tried to put it in perspective - because I realize there are people in the world with REAL problems, but that didn't seem to help last night.

I'll be glad when I'm home with my animals and surrounded by familiar things. It's comforting at times like these.

It's all in the details

Greetings from overcast, muggy Atlanta. Thus far, I have not been impressed with AVMA. Organization seems generally lacking. It's a much smaller conference than NAVC, but I'd trade the cattle drive like atmosphere of Orlando for the dull talks and bad organization here. I went to pick up my goody bag this morning at registration. Typically, it's filled with pens, notepads (for taking notes in lectures), a lanyard for your name badge and swipe card, and other stuff. Yeah, I had nothing but a schedule. Why? They ran out of lanyards and notepads. Seriously? I registered for this conference 3 months ago. They do it EVERY SINGLE year. They can't plan better for this? I brought nothing on which to take notes because conferences are (generally) so reliable about the nice notepad in the bag. The talks that I attended this morning were ER in nature, but they were very basic. I didn't glean much from them. Granted, this is a basic veterinary conference, not IVECCS, but still...I thought the lectures could be a bit more advanced.

I had lunch with a fellow blogger - one who follows me and vice versa, Hermit Thrush. It was really cool to meet someone that I've "known" for a while. Blogging creates such an interesting world!

That's really all to say here. If AVMA gets more interesting, I'll be sure to post. We're going to try to see the Georgia Aquarium tomorrow, so that should be fun at least.